Disease elimination and eradication: are our silos sustainable?

Dr. Richard Reithinger (@rreithinger) is Vice-President of the Global Health Division at RTI International. An epidemiologist specialised in malaria and other vector-borne diseases, Dr. Reithinger has published more than 100 peer-reviewed papers and is on the editorial boards of PLoS Neglected Tropical Diseases, BMC Infectious Diseases, and the Transactions of the Royal Society of Tropical Medicine & Hygiene.

Visionary goals to end diseases are all around us. Polio, Guinea worm, malaria, and a handful of other diseases have been identified as potentially eradicable – some as quickly as within a generation. Beyond optimistic goals, the day-to-day of disease elimination and eradication is complex and difficult: only one infectious disease that affects humans – smallpox – has ever even been eradicated. Progress has been made in every area that makes disease elimination and eradication possible – from diagnosis and treatment to mapping and modelling. Now, cross-disease discussions on the science, policy, and operational “must-haves” that have gotten us to this point are urgently needed.

A classic example is malaria and lymphatic filariasis (LF), two diseases both spread by the same group and – in some settings – the same species of mosquito.

The malaria community has long debated the use and effectiveness of mass drug administrations (MDA) among at-risk populations, particularly in pre-elimination settings. Meanwhile, the neglected tropical diseases (NTDs) community has been conducting MDAs for decades in its drive to eliminate LF by 2020. Supported by the RTI-led, USAID-funded ENVISION project, 272 million LF treatments have been distributed through large-scale annual treatment campaigns. As a result, 152 million people in 13 ENVISION-supported countries are no longer at risk for the disease.

Further, there could be rich lessons regarding the kind of impact that bednet distributions for malaria might have had on LF transmission in countries endemic for the two diseases.

We know we can’t be overly simplistic, given there are differences even at the basic level of how each disease defines elimination; for some diseases, it’s about reducing transmission to zero, and for others it’s about ensuring disease levels become so low that they are no longer public health problems.

In addition to increasing cross-disease learning, we should also discuss the integration of efforts into wider health systems. It’s a necessity that becomes more and more urgent as our progress continues.

Remaining cases also became more spotty, clustered, and located in hard-to-reach places and populations, with greater and greater geographic resolution needed to identify and respond to cases.

Through RTI’s decade-long support to Zanzibar’s malaria control programme, we learned that - besides political will, commitment, and financing - a strong surveillance system is the critical foundation for any push to elimination. In Zanzibar, a combination of interventions has reduced malaria prevalence to less than 1%, and state-of-the-art surveillance ensures that transmission remains at these low levels.

Nothing illustrates our continued tendency to talk past each other quite like the fact that two global health gatherings – the ASTMH annual meeting and the Global Symposium on Health Systems Research – are taking place this week. Separate streams of conversation, both in-person and online, are a missed opportunity for cross-disease and cross-sector conversations.

If there is broad agreement that disease elimination and eradication will only be possible if underpinned by strong health systems, we need to diligently make those links - like how elimination and eradication efforts could be integrated with wider health systems issues such as universal health care, decentralized health governance, or domestic resource mobilization.

Accelerating progress to build political will

Better collaboration between disease communities and more concerted linkages with health systems are critical to accelerate progress and to ensure funding and political will continues.

When the burden of a disease decreases in a given country, it’s certainly a cause for celebration, but it also becomes very difficult to maintain political will, commitment, and funding for vertical programming.

Thailand, for example, has made considerable progress against malaria, and international donors are now lessening support for malaria programming as a result. Current funding from the Thai government, however, is not sufficient to go the last mile. Thus, through the USAID-funded Inform Asia project, RTI is leading a cost-benefit analysis of malaria elimination in Thailand to help advocate for increased resources from the Thai government as well as non-government resources.

Globally, noble goals paired with tremendous progress have successfully rallied substantial commitments to finance disease control programmes. Just look at the Global Fund – its support has contributed to saving more than 20 million lives, and it recently raised $13 billion dollars to continue its work.

But if outcomes stagnate or stall, it will become increasingly difficult to preserve the attention of policymakers amidst other needs and emergencies also screaming for attention.

Caught in the day-to-day complexities of pushing for elimination and eradication of specific diseases, it can be hard to lift our head up, look around, and reach across our respective silos to ask thoughtful and tough questions, as well as get informed on how other disease communities tackle similar issues and challenges. However, it would benefit us all to do so, as it may well help us cross the finish line sooner, and reach the ambitious elimination and eradication goals that are - in some instances - at our fingertips.

Comments

Eliminating and eradicating diseases is a complex and continuing process. Although progress has been made in reducing the incidence and prevalence of certain diseases, there is still quite a long way to go. The primary focus of this blog is malaria and integrating efforts in wider health systems. Malaria, globally, is the 10th leading cause of death for all age groups. Not to mention, the substantial burden it creates for those affected. Integrating wider health systems can facilitate the progress of the eradication and elimination of diseases, such as malaria, by making the measures and goals geared towards this more efficient. In addition, integration of health services can also enhance the quality of care one receives.

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